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<meta name="description" content="读书笔记，感谢作者。阻生牙(impacted teeth)的成功拔除主要依靠正确的术前评估和计划，对术中可能出现的并发症的估计，以及对术后并发症的管理。因此要详细询问病史，仔细进行临床检查，以及进行影像学评估。阻生牙拔除的指征：有的医生建议尽快拔除，有的则认为对于无症状的阻生牙不必拔除。但对已经引起症状的阻生牙，是必须要建议拔除的。①局限性或广泛性头部神经痛（Localized or Genera">
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<meta property="og:description" content="读书笔记，感谢作者。阻生牙(impacted teeth)的成功拔除主要依靠正确的术前评估和计划，对术中可能出现的并发症的估计，以及对术后并发症的管理。因此要详细询问病史，仔细进行临床检查，以及进行影像学评估。阻生牙拔除的指征：有的医生建议尽快拔除，有的则认为对于无症状的阻生牙不必拔除。但对已经引起症状的阻生牙，是必须要建议拔除的。①局限性或广泛性头部神经痛（Localized or Genera">
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          <h1 class="post-title" itemprop="name headline">阻生牙拔除</h1>
        

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        <p>读书笔记，感谢作者。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/01.jpg"><br>阻生牙(impacted teeth)的成功拔除主要依靠正确的术前评估和计划，对术中可能出现的并发症的估计，以及对术后并发症的管理。因此要详细询问病史，仔细进行临床检查，以及进行影像学评估。<br>阻生牙拔除的指征：有的医生建议尽快拔除，有的则认为对于无症状的阻生牙不必拔除。但对已经引起症状的阻生牙，是必须要建议拔除的。<br>①局限性或广泛性头部神经痛（Localized or Generalized Neuralgias of the Head)<br>阻生牙可能导致各种类型的头痛和神经痛。很多可以归咎于阻生牙对各种神经末梢的压力。<br>②冠周炎（Pericoronitis)<br>覆盖半阻生牙（semi-impacted tooth）的软组织以及其盲袋（follicle）的急性软组织炎症。可能是由于对颌第三磨牙对软组织的创伤，或者由于食物残渣进入盲袋中。会反复发作。可能出现炎症区域剧烈疼痛，放射到耳颞部，以及下颌下区域。还可能有牙关紧闭，吞咽困难，下颌下腺淋巴炎，患区皮肤红肿，软组织红肿等症状。冠周炎的一个特征性症状是当按压覆盖阻生牙的软组织的时候，会有严重疼痛和溢脓等情况。急性炎症常扩散到颈部或者面部区域。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/02.jpg"><br>③造成龋坏：阻生牙或半阻生牙可能会因为食物残渣的滞留导致第二磨牙的远中龋坏。阻生牙本身也会产生龋坏。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/03.jpg"><br>④使第二磨牙的骨支持丧失：阻生牙的长期影响会导致第二磨牙远中的牙槽骨丧失。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/04.jpg"><br>⑤对局部义齿或全口义齿就位造成障碍：对有牙列缺损的患者，阻生牙可能在剩余牙槽嵴周围，给义齿修复带来问题。通常是疼痛和水肿。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/05.jpg"><br>⑥阻碍正常恒牙的萌出：阻生牙和多生牙可能阻碍正常恒牙的萌出，带来功能和美观的问题。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/06.jpg"><br>⑦导致或加剧正畸问题：牙弓空间不足是拔牙的一个最常见的原因，主要是阻生和半阻生的下颌第三磨牙。<br>⑧参与各种病理条件发展的阻生牙。囊性病变可围绕阻生牙牙冠发展，这种囊性病变可以扩展到整个颌骨区域。当影像学证实这种病损的存在后，相关的阻生牙必须被拔除。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/07.jpg"><br>⑨造成邻牙牙根外吸收的。由于阻生牙的直接压力导致的，主要发生在上下颌的后牙。开始发生于远中根，随后，可能扩展到整个牙齿。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/08.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/09.jpg"><br>除了上述情况，没有人能保证现在没有症状的阻生牙以后不会产生问题。对阻生牙是拔还是留的决策要在考虑了所有的可能性以后再做出。<br>拔除阻生牙的时机：最佳时机是患者年轻的时候。<br>外科拔除阻生牙的步骤：<br>①切开并翻粘骨膜瓣。<br>②去骨，暴露阻生牙。<br>③拔除阻生牙。<br>④拔牙窝处理，缝合。<br>手术成功的关键因素：①正确的瓣设计，必须基于临床和影像学检查（牙的位置，牙根与重要解剖结构的关系，牙根形态等）；②确保阻生牙拔除的通路的同时，尽量减少去骨。通过分根和分块取出患牙来达到，这样减少创伤。<br>拔除下颌阻生牙<br>下颌第三磨牙<br>分类：<br>根据萌出高度：高位，中位，低位。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/10.jpg"><br>根据牙冠与下颌升支前缘的关系：1类，间隙大于阻生牙牙冠近远中距离（不用去骨）；2类，间隙小于阻生牙牙冠近远中距离。3类，完全没有间隙。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/11.jpg"><br>阻生牙的牙根数目，形态，以及它们和下牙槽神经管的关系，都要考虑在内。3类难度更大，因为其要去的骨很多，增加下颌骨骨折和下颌管损伤的风险。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/12.jpg"><br>翻瓣的类型：主要使用两种瓣，三角瓣和信封瓣。主要根据临床情况进行选择。<br>三角瓣(Triangular flap）：<br>切口开始于升支的前缘（外斜线, external oblique ridge），注意不要损伤舌神经，扩展到第二磨牙远中，然后做垂直松弛切口斜向下外，止于前庭沟。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/13.jpg"><br>当阻生牙位置很深，为了保证良好的手术视野，或者当阻生牙隐藏在第二磨牙牙根处时，切口可以沿着颈缘延续到第一磨牙远中。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/14.jpg"><br>水平瓣（信封瓣）：<br>切口同样从下颌升支前缘开始，延伸到第二磨牙远中，沿着颈缘线(cervical lines）延伸至两颗磨牙，在第一磨牙近中终止。这种瓣主要用于阻生牙相对表浅的病例。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/15.jpg"><br>（我以前拔阻生牙的翻瓣方法都是错的，往往是能不翻瓣就不翻瓣，需要翻瓣去骨的病例都转走了。少数要翻的也常常是在拔的过程中才来翻瓣，翻的时候往往是从第二磨牙远中的地方做水平切口，再不行再从第二磨牙远中做垂直切口到前庭沟，虽然最后样子跟三角瓣也差不多，但是完全没这个概念，就是跟着感觉在操作。）<br>局部麻醉：用下牙槽神经阻滞麻醉、颊神经阻滞麻醉、舌神经阻滞麻醉、以及局部浸润麻醉。<br>拔除第三磨牙牙胚（bud of an impacted mandibular third molar）<br>牙根未发育完成的阻生牙。用15号刀片切口。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/16.jpg"><br>从第二磨牙远中翻粘骨膜瓣，一直翻到下颌升支前缘。球钻去骨，直到暴露整个牙冠。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/17.jpg"><br>如果牙根未发育，在用挺撬的时候患牙可能会进入更深的区域。因此这样的患牙拔除相对要困难一些。因此手术入路必须保证，通过在患牙颊侧和远中去除足够的骨。使在牙槽窝内用挺没有阻挡。（貌似去骨都是用慢直机？）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/18.jpg"><br>在充分暴露以后，用直挺以旋转力挺出患牙。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/19.jpg"><br>阻生牙完全拔除后，牙囊（follicular sac），通常在第二磨牙远中区域，以及骨碎片，必须被去除干净。检查骨边缘有无锐利的地方。如果有，用骨挫修整。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/20.jpg"><br>用盐水冲洗，缝合创面。第一针在瓣的角落处，以确保瓣的正确对位（应该是说在第二磨牙远中那个位置缝第一针）。其它针在后面以及垂直切口区。（可见每一针都是有讲究，不是乱来的）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/21.jpg"><br>拔除水平阻生的下颌第三磨牙<br>当牙齿在下颌骨的位置不是太深时，在做一个水平切口之后，翻开粘骨膜瓣。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/22.jpg"><br>用球钻将覆盖牙冠的牙槽骨去除，去骨时用稳定的生理盐水冲洗，直到牙冠完全暴露。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/23.jpg"><br>用裂钻沿与牙体长轴垂直的方向磨出一个凹槽，在患牙颈缘的地方，将牙冠和牙根分离。<br>（这是我拔水平阻生智齿的一个难点，分冠的时候方向往往不对，导致冠是部分下来了，挺剩余部分的时候还是有阻挡，所以之前就要设计清楚。）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/24.jpg"><br>凹槽不用太深，因为下颌管常常在接近牙齿的地方，太深有损伤下颌管及下牙槽神经的可能。（个人经验：磨到髓腔即可）用直挺伸到凹槽处，一用力，牙冠就与牙根分离了。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/25.jpg"><br>接着，用直挺或弯挺可以很容易的从牙根颊侧制造出来的间隙中把牙根挺出。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/26.jpg"><br>在平整骨面并用生理盐水冲洗以后，就可以缝合了。第一针在第二磨牙远中那里，然后再缝牙龈乳头区和后方的切口。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/27.jpg"><br>如果患牙有两个牙根，在分离牙冠和牙根后，如果牙根也分离了，那么就很容易拔了，否则，考虑分根。尤其是牙根弯曲的情况下。<br>近中倾斜阻生第三磨牙的拔除<br>当近中倾斜与第二磨牙接触点在颈缘或者颈缘以下的时候就要考虑先分冠再拔了。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/28.jpg"><br>切龈翻瓣与水平阻生牙拔除类似。翻瓣从第一磨牙近中龈乳头开始，向后延伸，一直到下颌升支前缘。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/29.jpg"><br>使用球钻去除覆盖在牙齿上的牙槽骨，直到整个牙冠暴露。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/30.jpg"><br>接着，用裂钻在颊侧以及主要的在远中，去除足够的骨。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/31.jpg"><br>如果阻生牙是单根，把牙齿近中部分先拔出，然后再拔除其余部分。如果是双根，先分根，再从方便的方向拔除，主要看牙根的弯曲程度。<br>具体来说，用裂钻在牙冠上制造一个深的垂直的凹槽，大概磨到牙槽间隔的地方。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/32.jpg"><br>用直挺，插入凹槽内，旋转就可以把牙根分开。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/33.jpg"><br>这种方法可以减少去骨，术后肿胀，并使手术过程加快。<br>分两个步骤拔除患牙。首先将远中根连同部分牙冠挺出。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/34.jpg"><br>接着把挺刃放在牙齿近中，拔除患牙的其它部分。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/35.jpg"><br>小心处理牙槽窝，按前述方法缝合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/36.jpg"><br>拔除颊舌向阻生的第三磨牙<br>这类患牙的拔除被认为非常困难，因为它在下颌升支前缘之下，牙冠上方有大量骨覆盖，而且其牙根有靠近第二磨牙的倾向。因此，无法完整拔除患牙，除非大量去骨。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/37.jpg"><br>翻瓣去骨的方法如前所述。<br>唯一不同的是分牙，目标是使需要去骨的量最少。用裂钻分离远中牙冠，接着再用挺从患牙近中拔除剩下的部分。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/38.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/39.jpg"><br>然后清理拔牙创，缝合。<br>第二磨牙缺失的患者拔除第三磨牙<br>相比来说拔牙更迅速和容易。翻瓣去骨如前所述，只是不需要再分牙了。<br>阻生前磨牙的拔除<br>可以在颊侧或者舌侧，垂直向，其牙冠经常在邻牙的下方。<br>如果定位在颊侧（最好用CT）。小心的翻梯形瓣，做垂直切口，防止损伤到神经。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/40.jpg"><br>翻瓣后小心去骨，防止损伤到邻牙。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/41.jpg"><br>用裂钻从牙颈部区域分离牙冠和牙根，然后用直挺拔除牙冠。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/42.jpg"><br>接着，牙冠被拔除。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/43.jpg"><br>然后用一个弯挺（angled elevator）拔除牙根，挺刃放在根的颊侧制造的缝隙内。很容易向上挺拔除牙根。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/44.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/45.jpg"><br>(阻生尖牙的拔除略了。）<br>上颌阻生牙的拔除<br>上颌第三磨牙阻生<br>拔除较困难，因为视线不理想，入路受限。其它因素（开口度降低，上颌阻生牙接近上颌窦等）可能使手术拔除患牙更困难。<br>分类<br>根据位置（Archer, 1975）：近中阻生，远中阻生，垂直阻生，水平阻生，颊向阻生，舌向阻生，或者倒转阻生。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/46.jpg"><br>患牙常向近中或远中倾斜，咬合面常向颊侧。<br>根据相对第二磨牙的深度(Archer, 1975)<br>A类 阻生牙的咬合平面与第二磨牙咬合平面在同一水平。<br>B类 阻生牙咬合平面在邻牙的牙冠中间。<br>C类 阻生牙咬合平面在邻牙颈缘以下。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/47.jpg"><br>C类是很困难的病例，因为拔除它们需要去大量的牙槽骨，通路有限，以及阻生牙进入上颌窦的风险。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/48.jpg"><br>瓣的类型：三角瓣(triangular)和水平瓣(horizontal)<br>三角瓣:切口从第二磨牙远中开始，斜向上，同时前方垂直切口到达前庭沟。<br>极少的情况下，如果阻生牙位置比较深，或者阻生牙在第二磨牙牙根的颊侧，也可以在第一磨牙远中做垂直切口。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/49.jpg"><br>水平（信封）瓣<br>切口在上颌结节处开始，延展到第二磨牙远中，在颊侧沿着最后两颗牙的颈缘线延续，在第一磨牙近中结束。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/50.jpg"><br>通常，在翻瓣以后，阻生牙的部分牙冠已经暴露，或者有牙槽骨覆盖在阻生牙上。因为覆盖的骨很薄并且有弹性，可以用一些尖锐的器械将其去除。如果骨较密实较厚，用外科钻来去骨。<br>拔除上颌第三阻生磨牙<br>三角切口，翻信封瓣。去骨直到所有牙冠和部分牙根暴露。由于没有分牙的指征，牙冠周围必须有足够的空间以拔除患牙。用直挺或者双角挺在颊侧近中拔除患牙。方向向外向下。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0014-zsybcs/51.jpg"><br>复位，缝合。<br>(阻生尖牙，其它阻生牙，腭侧拔牙等暂时略了）<br>总结，拔牙就完了。基本思想是该翻瓣的翻瓣，该去骨的去骨，该分牙分根就分牙分根，暴露整个牙冠和部分牙根，就好拔了。像我以前那样，只知道硬挺，往往就等着掏根吧。另外就是在牙槽骨或者牙齿上制造凹槽，给挺提供支点。还有我拔牙最大的一个问题：往往牙齿挺松了，就是拿不下来，想好多办法，最后往往还得分牙分根，干嘛不一开始就分好呢？</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>

      
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